Part 1 PERSONAL INFORMATION (Please print.)

Name of claimant: ______________________________________________________________________________________________________________________

Sex: ❏ F ❏ M Date of birth: ________ /________ / ________

Home address: ________________________________________________________________________________________________________________________

City: __________________________________________ Province: __________________________ Postal code: ______________ Country: ______________

Home telephone: ( ________ ) ______________ - ________________ Home fax: ( ________ ) ____________ - ______________

Office telephone: ( ________ ) ______________ - ________________ Office fax: ( ________ ) ____________ - ______________

Other (cellular telephone/email address/toll-free number) — Please specify: ________________________________________________________________________

Reason for travelling: ❏ Pleasure ❏ Business Your occupation: ______________________________________________________

Part 2 INSURANCE POLICY (Please print.)

Policy number: ________________________________________________________________

Travel agency: ________________________________________________________________ Telephone: ( ________ ) ________ - __________

Part 3 THE INCIDENT (Please print.)

Claiming for: ❏ Delay ❏ Loss ❏ Damage ❏ Theft

Date of incident: ______ / ______ / ______ City where loss occurred: ______________________________________________________________

Did you file a report with the police or another authority? ❏ Yes ❏ No Included: __________________________________________________

IF YOU ARE PROVIDING A REPORT OR PROOF OF YOUR LOSS, YOU MUST ALSO PROVIDE AN EXPLANATION LETTER.

Flight departing from: ____________________________ Date: ______ / ______ / ______ Airline:______________________________ Flight No: ____________

Final destination: ________________________________ Date: ______ / ______ / ______ Airline:______________________________ Flight No: ____________

Airline that lost the baggage: ______________________________________________________________________________________________________________

Number of checked baggage: __________________________________________ Number of lost or delayed baggage: __________________________________

Date you received the baggage: ________ / ________ / ________ Number of hours delayed: __________________________________________

Part 4 OTHER INSURANCE (Please print.)

Were your baggage and personal effects covered by another insurance plan? ❏ Yes ❏ No

Type of insurance (home, specific, group, credit card, travel, other) — Please specify:__________________________________________________________

Name of the insurance company: ______________________________________________________ Telephone: ( ________ ) ________ - ________________

Name of your agent: ________________________________________________________________ Telephone: ( ________ ) ________ - ________________

Insurance policy number: ____________________________________________________________ Expiry date: __________ / __________ / __________

Did you pay for your travel arrangements with a credit card? ❏ Yes ❏ No

If yes: Card no: ____________________________________________________ Bank name: ____________________________________________________

NOTE: Please indicate the requested information for any other insurance policy that covers your baggageand personal effects.

D M Y

D M Y

D M Y

D M Y

D M Y

D M Y

CLAIM FORMBAGGAGE AND PERSONAL EFFECTS INSURANCE

Part 5 DOCUMENTS REQUIRED (Please attach these documents to your claim form.)

1. The completed baggage claim form and the detailed list of items claimed.

2. A copy of the insurance policy.

3. Proof that you filed a claim with the airline for the same list of items upon return from your trip, where applicable, as well as proof of the airline’s payment orrefusal of your claim.

4. A report by the police and by the hotel manager, tour guide or transportation authorities in whose custody the insured property was at the time of loss.

5. Adequate proof of loss, ownership and itemized value along with a detailed statement within 90 days from the date of loss.

6. A Property Irregularity Report when luggage is lost or damaged while in the custody of the airline.

7. Airline tickets or airline invoice (for all baggage claims).

8. Original receipts indicating the value, the purchase date, and name of the business where each item was purchased or any proof of ownership such asguarantee, credit card voucher, instruction booklet or picture.

9. Estimate or original receipts for expenses incurred to repair damaged luggage.

For a baggage delay, please provide the following additional information:

10. Original itemized receipts for expenses actually incurred and description of items purchased.

11. A copy of the baggage claim ticket and the delivery receipt.

12. Verification of the delay of checked baggage from the airline including the reason and the duration of the delay.

NOTE: If you are unable to complete this claim form or provide the information as requested, please providean explanation.

Part 6 AUTHORIZATION AND CLAIMANT’S STATEMENT

I consent, authorize and accept that this claim form is a written document containing information that Global Excel Management Inc., its employees or the employees of itsproviders, and the insurer (including the company or companies and/or person(s) named in this claim form) will use and divulge solely for the purpose of verifying, assessing,adjudicating and/or accelerating the claim.

I understand that the information I provide to Global Excel Management Inc. is confidential and that every necessary measure will be taken to ensure the confidentiality ofmy private information.

I declare that the information provided on this claim form is true and accurate. I understand that any false information or statement will rendermy coverage null and void and that all documents will be returned to me , thereby discharging Global Excel Management Inc. and the insurerfrom any liability or obligation.

I, the undersigned, certify that I have sent the same list of items to the airline concerned upon my return from the trip. I hereby authorize andtransfer my rights of recovery against any other responsible parties to Global Excel Management Inc. with respect to any sum paid by theaforesaid company for all risks covered by this policy.

Date of this claim form: _______ / _______ / _______

Signature of the insured person or the claimant: ______________________________________________________________________

D M Y

Insured Person: File No.:

No Items (essential nessities, stolen or lost) Place/Date of Purchase Original Price Replacement Cost Depreciation Cash Value Benefit Limit

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

Any false statement shall be considered a forfeit of the Insured Person’s right to filea claim for that particular risk.

TOTAL:

List of items claimed

I, the undersigned, certify that to the best of my knowledge, all of the above information is correct and true and that I HAVE SENT THE SAME LIST OF ITEMS TO THE AIRLINE CONCERNEDUPON MY RETURN FROM THE TRIP. I hereby authorize and transfer my rights of recovery against any other responsible parties to Global Excel Management Inc., with respect to any sumpaid by the aforesaid company for all risks covered by this policy.

____________________________________________________ ______________________________________________ __________________________________________________Signature of the Insured Person Date Signature of a witness